1. What is the Affordable Care Act?

The Patient Protection and Affordable Care Act, commonly called the ACA or Obamacare, was signed into law by President Obama on March 23, 2010. The law seeks to reform health care in the United States through numerous provisions that go into effect over the course of eight years.Return to top

2. Are dental benefits included in the ACA?

While dental benefits sold in Standalone policies (not part of medical policies) are generally not subject to most ACA requirements, there are some exceptions. Pediatric dental benefits (for those under age 19) are part of the Essential Health Benefits Package (EHB), which must be offered by insurers and meet state-specific benefit standards. Some administrative contracts for larger employers are also impacted.Return to top

3. What are “Essential Health Benefits” or EHBs?

EHBs are ten benefit categories that must be covered by health insurers in order for those plans to be EHB or Exchange-certified:

For the most part, plans cannot impose annual or lifetime maximums (aka limits) on these services.Return to top

4. What is a Health Insurance Exchange?

A Health Insurance Exchange (also called a “Marketplace”) is a resource available in each state for learning about and purchasing health insurance coverage. In New Mexico there is the Individual Health Insurance Exchange and the Small Business Health Options Program or “SHOP” Exchange for small employers.Return to top

5. I work for a small business and my employer currently offers dental benefits. Will I be required to get my insurance on the Health Insurance Exchange?

Employers are not required to purchase dental coverage through the Exchange. Employers can keep their current dental benefits with the same insurance carrier. Delta Dental of New Mexico offers Exchange-certified plans and products, which meet ACA requirements.Return to top

6. Is orthodontia covered under the new Exchange-Certified Pediatric Dental Benefit?

Delta Dental plans that include an Exchange-certified pediatric dental benefit cover child-only “medically necessary” orthodontia. This is consistent with the Medicaid/CHIP Benchmark established by New Mexico. Medically necessary orthodontia is more restrictive than Delta Dental’s standard orthodontic coverage. Return to top

7. What happens if I do not purchase health benefits?

Most individuals are required to have “minimum essential coverage”. The following are acceptable forms of coverage: individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE or certain other coverage. Those who choose not to purchase health benefits may have to pay penalties. Return to top

8. Am I required to purchase dental benefits?

Individuals are not required by New Mexico or the Federal Government to purchase dental benefits in order to meet the test of minimum essential coverage. Likewise, small employers are not required to offer dental benefits. Medical insurers may choose to include dental benefits with their medical plans, but are not required to do so (NM OSI Bulletin 2014-017).Return to top

9. Will my health insurance cover dental?

Some health insurance plans may include “embedded” or “bundled” dental plans. It is important to understand how those benefits work. Embedded or bundled dental plans may require you to meet a much larger medical deductible before your dental services will be eligible for coverage. Standalone dental plans like Delta Dental do not have the same restrictions. If your benefits are embedded in a medical plan, you may want to check your options for a supplemental individual dental plan. (Click here for more information on individual plans.)Return to top

10. Do I have to see a specific dentist for care?

Individuals who purchase individual or small-group dental coverage will need to see a dentist that participates in that plan’s network to maximize their benefits. The limits on out-of-pocket costs may not apply to dentists not in the plan’s network.Return to top

11. Are the adult and pediatric benefits different?

Adults purchasing dental benefits through the Exchange or a plan that includes an EHB/Exchange-certified pediatric dental benefit may have different benefits than their children/dependents under the age of 19. With Delta Dental benefits, you will be able to see the same network dentist for care if you prefer.Return to top

12. Is dental coverage offered on the New Mexico Health Insurance Exchange?

The NM Health Insurance Exchange currently offers a limited number of dental insurance plans through its website. Delta Dental does not currently participate on the NM Health Insurance Exchange.Return to top

13. If my employer or I purchase medical insurance through the Exchange, is it still possible to have dental insurance through Delta Dental?

You and/or your employer are still able to purchase dental insurance through Delta Dental of New Mexico even if you buy your medical coverage on the Exchange. Please click here for more information on individual plans or have your employer contact us here.Return to top

14. Are group dental premiums covered by the tax incentives for health care coverage?

Small employers (less than 25 employees) that cover at least 50% of the cost of single (not family) health care coverage for each of their employees and whose employees have average wages of less than $50,000 a year may be eligible for tax credits when they purchase medical coverage for their employees. This does not apply to dental coverage, and the tax credits are only available when purchasing in the Exchange during the initial two years. It is important to note that the employer receives the tax credits, not the employee.Return to top

15. How do subsidies work for individuals? Do they cover dental?

Individuals who are at or below 400 percent of the Federal Poverty Level (FPL) are eligible to receive subsidies to help with insurance premiums when they purchase coverage through the Individual Exchange. They will not receive subsidies if they purchase coverage through their employer. Subsidies cannot be used to purchase adult dental benefits. Note that if an employer covers part of the cost of an employee’s benefits, the employee is not eligible for subsidies through the Individual Exchange.Return to top

Disclaimer: This information is not intended to serve as legal advice and only constitutes Delta Dental of New Mexico’s understanding of the subject. Please consult your attorney and/or accountant for more information about how the ACA may impact you or your business.

The information provided on this site is for general education purposes only and is not intended as a diagnosis, treatment, or a substitute for professional medical or dental advice, diagnosis, or treatment. Consult your dentist or physician for information or treatment specific to you and your health.